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  1. Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists. | PSNet

    psnet.ahrq.gov/issue/implementation-telepharmacy-service-provide-round-clock-medication-order-review-pharmacists
    September 22, 2010 - Commentary Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists. Citation Text: Wakefield DS, Ward MM, Loes JL, et al. Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists. Ameri…

  2. Patient and family empowerment as agents of ambulatory care safety and quality. | PSNet

    psnet.ahrq.gov/issue/patient-and-family-empowerment-agents-ambulatory-care-safety-and-quality
    December 15, 2021 - Commentary Patient and family empowerment as agents of ambulatory care safety and quality. Citation Text: Roter DL, Wolff JL, Wu AW, et al. Patient and family empowerment as agents of ambulatory care safety and quality. BMJ Qual Saf. 2017;26(6):508-512. doi:10.1136/bmjqs-2016-005489. C…

  3. Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage 7: a case report. | PSNet

    psnet.ahrq.gov/issue/improving-inpatient-mental-health-medication-safety-through-process-obtaining-himss-stage-7
    July 17, 2019 - Commentary Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage 7: a case report. Citation Text: Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage 7: a case report. Sulkers H, Tajirian T, Paterson …

  4. Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study. | PSNet

    psnet.ahrq.gov/issue/task-errors-emergency-physicians-are-associated-interruptions-multitasking-fatigue-and
    March 29, 2017 - Study Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study. Citation Text: Westbrook JI, Raban MZ, Walter SR, et al. Task errors by emergency physicians are associated with interr…

  5. Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry. | PSNet

    psnet.ahrq.gov/issue/interventional-procedures-outside-operating-room-results-national-anesthesia-clinical
    March 06, 2019 - Study Emerging Classic Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry. Citation Text: Chang B, Kaye AD, Diaz JH, et al. Interventional Procedures Outside of the Operating Room: Results Fro…

  6. The relationship between early emergency team calls and serious adverse events. | PSNet

    psnet.ahrq.gov/issue/relationship-between-early-emergency-team-calls-and-serious-adverse-events
    June 02, 2010 - Study The relationship between early emergency team calls and serious adverse events. Citation Text: Chen J, Bellomo R, Flabouris A, et al. The relationship between early emergency team calls and serious adverse events. Crit Care Med. 2009;37(1):148-53. doi:10.1097/CCM.0b013e3181928ce3…

  7. Beyond the medical record: other modes of error acknowledgment. | PSNet

    psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
    August 03, 2009 - Study Beyond the medical record: other modes of error acknowledgment. Citation Text: Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error acknowledgment. J Gen Intern Med. 2005;20(5):404-9. Copy Citation Format: Google Scholar PubMe…

  8. Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit. | PSNet

    psnet.ahrq.gov/issue/interventions-reduce-medication-prescribing-errors-paediatric-cardiac-intensive-care-unit
    November 16, 2022 - Study Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit. Citation Text: Burmester MK, Dionne R, Thiagarajan RR, et al. Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit. Intensive Care Med. …

  9. Nurses' use of computerized clinical guidelines to improve patient safety in hospitals. | PSNet

    psnet.ahrq.gov/issue/nurses-use-computerized-clinical-guidelines-improve-patient-safety-hospitals
    June 06, 2018 - Review Nurses' use of computerized clinical guidelines to improve patient safety in hospitals. Citation Text: Hovde B, Jensen KH, Alexander GL, et al. Nurses' Use of Computerized Clinical Guidelines to Improve Patient Safety in Hospitals. West J Nurs Res. 2015;37(7):877-98. doi:10.1177/0…

  10. Briefing and debriefing in the operating room using fighter pilot crew resource management. | PSNet

    psnet.ahrq.gov/issue/briefing-and-debriefing-operating-room-using-fighter-pilot-crew-resource-management
    May 29, 2024 - Study Briefing and debriefing in the operating room using fighter pilot crew resource management. Citation Text: McGreevy JM, Otten TD. Briefing and debriefing in the operating room using fighter pilot crew resource management. J Am Coll Surg. 2007;205(1):169-76. Copy Citation Fo…

  11. In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States. | PSNet

    psnet.ahrq.gov/issue/hospital-sequelae-injurious-falls-24-medicalsurgical-units-four-hospitals-united-states
    December 12, 2012 - Study In-hospital sequelae of injurious falls in 24 medical/surgical units in four hospitals in the United States. Citation Text: Hill A-M, Jacques A, Chandler M, et al. In-Hospital Sequelae of Injurious Falls in 24 Medical/Surgical Units in Four Hospitals in the United States. Jt Comm J…

  12. The 2011 duty-hour requirements—a survey of residency program directors. | PSNet

    psnet.ahrq.gov/issue/2011-duty-hour-requirements-survey-residency-program-directors
    December 02, 2014 - Study The 2011 duty-hour requirements—a survey of residency program directors. Citation Text: Drolet BC, Khokhar MT, Fischer SA. The 2011 duty-hour requirements--a survey of residency program directors. N Engl J Med. 2013;368(8):694-7. doi:10.1056/NEJMp1214483. Copy Citation Form…

  13. Analgesic-related medication errors reported to US Poison Control Centers. | PSNet

    psnet.ahrq.gov/issue/analgesic-related-medication-errors-reported-us-poison-control-centers
    June 06, 2018 - Study Analgesic-related medication errors reported to US Poison Control Centers. Citation Text: Eluri M, Spiller HA, Casavant MJ, et al. Analgesic-Related Medication Errors Reported to US Poison Control Centers. Pain Med. 2018;19(12):2357-2370. doi:10.1093/pm/pnx272. Copy Citation …

  14. Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out? | PSNet

    psnet.ahrq.gov/issue/patient-identification-error-among-prostate-needle-core-biopsy-specimens-are-we-ready-dna
    March 12, 2025 - Study Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out? Citation Text: Suba EJ, Pfeifer JD, Raab SS. Patient identification error among prostate needle core biopsy specimens--are we ready for a DNA time-out? J Urol. 2007;178(4 Pt …

  15. Perceived factors associated with sustained improvement following participation in a multicenter quality improvement collaborative. | PSNet

    psnet.ahrq.gov/issue/perceived-factors-associated-sustained-improvement-following-participation-multicenter
    November 20, 2019 - Study Perceived factors associated with sustained improvement following participation in a multicenter quality improvement collaborative. Citation Text: Stone S, Lee HC, Sharek PJ. Perceived Factors Associated with Sustained Improvement Following Participation in a Multicenter Quality Im…

  16. Diagnostic accuracy of emergency nurse practitioners versus physicians related to minor illnesses and injuries. | PSNet

    psnet.ahrq.gov/issue/diagnostic-accuracy-emergency-nurse-practitioners-versus-physicians-related-minor-illnesses
    April 13, 2022 - Study Diagnostic accuracy of emergency nurse practitioners versus physicians related to minor illnesses and injuries. Citation Text: van der Linden C, Reijnen R, De Vos R. Diagnostic accuracy of emergency nurse practitioners versus physicians related to minor illnesses and injuries. J E…

  17. Prevalence and sources of duplicate information in the electronic medical record. | PSNet

    psnet.ahrq.gov/issue/prevalence-and-sources-duplicate-information-electronic-medical-record
    October 21, 2020 - Study Prevalence and sources of duplicate information in the electronic medical record. Citation Text: Steinkamp J, Kantrowitz JJ, Airan-Javia S. Prevalence and sources of duplicate information in the electronic medical record. JAMA Netw Open. 2022;5(9):e2233348. doi:10.1001/jamanetworko…

  18. Agreement of expert judgment in causality assessment of adverse drug reactions. | PSNet

    psnet.ahrq.gov/issue/agreement-expert-judgment-causality-assessment-adverse-drug-reactions
    November 29, 2023 - Study Agreement of expert judgment in causality assessment of adverse drug reactions. Citation Text: Arimone Y, Bégaud B, Miremont-Salamé G, et al. Agreement of expert judgment in causality assessment of adverse drug reactions. Eur J Clin Pharmacol. 2005;61(3):169-73. Copy Citation …

  19. Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper. | PSNet

    psnet.ahrq.gov/issue/principles-patient-and-family-partnership-care-american-college-physicians-position-paper
    March 14, 2018 - Commentary Emerging Classic Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper. Citation Text: Nickel WK, Weinberger SE, Guze PA, et al. Principles for Patient and Family Partnership in Care: An American Colle…

  20. Medication errors associated with transition from insulin pens to insulin vials. | PSNet

    psnet.ahrq.gov/issue/medication-errors-associated-transition-insulin-pens-insulin-vials
    May 29, 2019 - Study Medication errors associated with transition from insulin pens to insulin vials. Citation Text: Trimble AN, Bishop B, Rampe N. Medication errors associated with transition from insulin pens to insulin vials. Am J Health Syst Pharm. 2017;74(2):70-75. doi:10.2146/ajhp150726. Copy C…
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